Burden of drug-susceptible tuberculosis in Indonesia

Iskandar, D., Suwantika, A.A., Pradipta, I.S., Postma, M.J. and van Boven, J.F., 2023. Clinical and economic burden of drug-susceptible tuberculosis in Indonesia: national trends 2017–19. The Lancet Global Health, 11(1), pp.e117-e125.

Globally, tuberculosis incidence is decreasing, but it remains high in Indonesia despite improvements in access to health services, funding, surveillance, diagnostics, situation analysis, and policy focus. Indonesia's national tuberculosis information system, Sistem Informasi Tuberkulosis (SITB), captures patient-level data, providing valuable real-world insights that can benefit the country’s evaluation and policymaking process. This real-world data offers detailed trends in actual cases and care, allowing for the assessment of potential efficacy–effectiveness gaps.

Between 2017 and 2019, the annual number of notified cases of drug-susceptible tuberculosis in Indonesia gradually increased, and treatment success rates improved. Rapid molecular test uptake for diagnosis also increased significantly; however, less than half of the recommended microbiological tests for treatment monitoring were performed. The costs of drug-susceptible tuberculosis treatment remained stable, and the treatment success rate slightly improved during this period, even surpassing the global trend. However, mortality rates remained relatively stable.

Several retreatment cases were identified in this study, which might be one of the contributing factors to the stable mortality rate. Retreatment cases and patients who do not show sputum conversion in the second month require extra attention, as they are associated with poor treatment outcomes.

Outpatient direct medical costs totaled $40 for one six-month course of therapy, comparable to previous estimates of $48. Another study divided costs into pre-treatment costs ($33) and post-diagnosis costs ($12), with an average total of $44. However, estimating costs using a fraction of the capitation fee for visits may underestimate the actual cost, particularly in private facilities. In fact, a sensitivity analysis using a broader costing perspective resulted in higher costs. Using an alternative visit cost estimation, the total direct medical cost per patient increased by approximately 1.5 times, from $39.37 to $58.33.

Given the high number of under-reported cases in Indonesia, generalizing these findings to all tuberculosis cases should be done cautiously, as this study focused solely on drug-susceptible tuberculosis. Another limitation is the inability to confirm whether tuberculosis was the cause of death based on ICD codes, and the cost analysis was restricted to direct medical costs only. 

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